ΜΕΜΑ σε οξύ πνευμονικό οίδημα Ηρακλής Τσαγκάρης 2η Πανεπιστημιακή Κλινική Εντατικής Θεραπείας Αττικό Νοσοκομείο

Acute Cardiogenic Pulmonary Oedema Common - 15-20,000 hospital admissions per annum in UK Deadly - 15-20% in-hospital mortality Costly - 6.5 million hospital days per annum in USA Acute pulmonary edema represents nearly 20% of acute heart failure cases. The diagnostic criteria of this syndrome have not been universally established. Sudden onset of severe dyspnoea /the presence of typical signs on physical examination /alveolar oedema on chest radiograph / and acute respiratory failure Eur Heart J. 2008;29:2388-442

Differences and similarities of acute pulmonary edema (APE) and acutely decompensated chronic heart failure (ADHF) Parissis, Eur J Heart F, 2010

Standard CPE therapy Loop Diuretic Therapy Nitrate Therapy Oxygen Therapy (Opiates) Treat Underlying Cause

Οξύ καρδιογενές πνευμονικό οίδημα ελαστικού φορτίου  φορτίου αντιστάσεων (Noble, JAP 1975) Οι αν. μύες παράγουν  πίεση για ικανοποιητική ροή και VT  αρνητικής ενδοθωρακικής πίεσης   προφορτίου και μεταφορτίου των κοιλιών (Hall, JAP 1998)  ενεργειακού κόστους αναπνοής   μεταφοράς Ο2 στο μυοκάρδιο

Targets of ventilation in cardiogenic pulmonary oedema improvement of oxygenation improvement of respiratory acidosis reduction of work of breathing improvement of cardiac performance reduction of patient’s distress

Physiological Improvement with CPAP in Pts with CardPE Kelly et al. Eur Heart J 2002;23:1379-1386

Non-invasive Ventilation In Acute Cardiogenic Pulmonary Oedema “When the household vacuum cleaner is employed, the machine should be run for some minutes first of all to get rid of dust” Poulton EP, Oxon DM: Left-sided heart failure with pulmonary oedema: Its treatment with the "pulmonary plus pressure machine." Lancet (1936);231:981-983.

354 consecutive pts 7 centers EUR+USA

When to start NIV in CPE Patients with pH <7.25 or systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for NIV. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation. Masip J, et al. Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema. Intensive Care Med 2003;29:1921-1928

NIV failure in CPE: decide early Worsening encephalopathy/agitation Inability to clear secretion Inability to accept any interface Hemodynamic instability Worsening oxygenation Progressive respiratory acidosis (pH<7.2) Persistent tachypnea-tachycardia

Effects of Noninvasive Ventilation on Mortality Masip et al, JAMA 2005;294:3124-3130

RR 0.53 Mortality reduced from 22% to 11% (95% CI 0.35-0.81) (Individual Group Sizes of n = 9 to 46) Masip et al. JAMA 2005;294:3124-3130

Effects of Noninvasive Ventilation on Need to Intubate Masip et al, JAMA 2005;294:3124-3130

Effects of Continuous Positive Airway Pressure vs Noninvasive Pressure Support Ventilation Masip et al, JAMA 2005;294:3124-3130

NIV for CPE (Cochrane Review): Mortality Vital FMR. et al., 2008

NIV for CPE (Cochrane Review): Intubation rate Vital FMR. et al., 2008

3-CPO In patients with acute cardiogenic pulmonary oedema: Aims Clinical effectiveness of non-invasive ventilation Comparative effectiveness of CPAP and NIPPV Safety of non-invasive ventilation Hypothesis: Non-invasive ventilation reduces mortality Gray et al NEJM 2008; 359:142-51

CPOE3: Standard vs CPAP vs NIPPV 26 hospitals in the UK, open, randomized, controlled, multicentre trial, in the ED Designed to evaluate the effect of NIV on Pulmonary Edema mortality compared with standard therapy to compare the effectiveness of CPAP vs. NIPPV 1069 patients, hospitalized with pulmonary edema, tachypnea (>20 breaths/min) and acidosis Randomized to at least 2 h of 60% O2 delivered either by standard face mask (n=367), CPAP (n=346) or NIPPV (n=356) Gray et al NEJM 2008; 359:142-51

3-CPO:baseline characteristics Standard CPAP NIPPV All Number 367 346 356 1069 Age (years) 78.7 77.6 77.2 77.8 Sex (male) 42% 45% 43% Sx of MI at Presentation 22% Ischemic heart disease 63% 65% 60% Congestive heart failure 47% 44% Valvular heart disease 12% 11% 9% COPD 19% 15% 21% 18% Hypertension 56% 55% 57% Diabetes Mellitus 30% 33% 31% Hypercholesterolemia 32% Current Smoker 16% PVD 10% Cerebrovascular disease 17% Gray et al NEJM 2008; 359:142-51

3-CPO:Immediate therapeutic interventions Standard CPAP NIPPV All Nitrate Therapy 93% 88% 91% 90% Diuretic Therapy 89% Opiate Therapy 3% 5% 4% Inspired Oxygen (L/min) 12±4 13±4 Ventilation Pressure (cmH2O) - 10±4 14±5/7±2

CPOE3:Standard vs CPAP vs NIPPV P-value Treatment allocated 365 342 351 Started allocated treatment 365 (100%) 336 (98.2%) 341 (97.2%) 0.07 Completed allocated treatment 298 (83.2%) 284 (84.5%) 265 (77.7%) 0.016 Not tolerated 1 (0.3%) 18 (5.4%) 30 (8.8%) <0.001 Worsening ABGs 26 (7.1%) 10 (3.0%) 15 (4.4%) 0.027 Respiratory distress 31 (8.5%) 5 (1.5%) 12 (3.5%) Other reason 17 (4.6%) 24 (7.1%) 25 (7.3%) 0.152 Changed to standard 3 (0.8%) 32 (9.5%) 51 (15.0%) Changed to CPAP 43 (11.8%) Gray et al NEJM 2008; 359:142-51

3-CPO Physiological Response to Intervention: One Hour Physiology Standard CPAP or NIPPV P Value (t-test) Pulse rate (/min) 102±23 96±22 <0.001 Systolic BP (mmHg) 128±30 124±27 0.073 Diastolic BP (mmHg) 65±20 66±18 0.390 Respiratory Rate (/min) 26±6 25±6 0.023 Oxygen Saturation (%) 94±6 93±6 0.044 Arterial pH 7.30±0.08 7.32±0.08 Arterial pO2 (kPa) 14.1±8.5 13.0 ±9.0 0.074 Arterial pCO2 (kPa) 6.7±2.5 6.2±1.9 Bicarbonate (mmol/L) 22±8 22±6 0.934 Gray et al NEJM 2008; 359:142-51

CPOE3:Standard vs CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

CPOE3: CPAP vs NIPPV Gray et al NEJM 2008; 359:142-51

CPOE3:CPAP vs NIPPV CPAP NIPPV OR 95% CI P Value 7-Day Mortality 9.6% 9.4% 0.97 0.59 to 1.61 0.912 Mortality/ Intubation 11.7% 11.1% 0.94 0.59 to 1.51 0.806 30-Day 15.4% 0.99 0.65 to 1.51 0.976 Gray et al NEJM 2008; 359:142-51

3-CPO In patients with acute cardiogenic pulmonary oedema, non-invasive ventilation: Produces more rapid resolution of metabolic abnormalities and respiratory distress Has no major effect on 7-day or 30-day mortality Is beneficial irrespective of the mode (CPAP or NIPPV) of delivery Gray et al NEJM 2008; 359:142-51

Masip, Mebazaa, NEJM 2008, 359:2068

CPAP vs NIPSV: Intubation rate Argawal, Singapore Med 2009 P=0.97 P0.46 P=0.49

Early vs late CPAP in the out-of-hospital environment Plaisance P et al. Eur. Heart J. 2007; 28:2895

* p < 0,05 Early vs late CPAP Plaisance P et al. Eur. Heart J. 2007; 28:2895

Early vs late CPAP Early CPAP Late p-value Intubation Rate 6 16 0,01 Intubation between T0 and T15 1 8 Need for Dobutamine 5 0,02 In-hospital Mortality 2 0,05 Plaisance P et al. Eur. Heart J. 2007; 28:2895

Early vs late CPAP in the out-of-hospital environment Conclusion: When compared to usual medical care, immediate application of CPAP alone in out-of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality. Plaisance P et al. Eur. Heart J. 2007; 28:2895

Boussignac CPAP Vygon Boussignac CPAP maximum pressure: 8 mbar CPAP device: Vygon Boussignac CPAP maximum pressure: 8 mbar Cigada M et al. Novel indications for the Boussignac CPAP valve. Intensive Care Med 2007;33:374-375.

Πνευμονικό οίδημα και NIV To οξύ πνευμονικό οίδημα αποτελεί προνομιακό πεδίο εφαρμογής του ΝΙV Τόσο η CPAP όσο και ο NIPPV μειώνουν στον ίδιο βαθμό την ανάγκη για διασωλήνωση και βελτιώνουν τη δύσπνοια και τις φυσιολογικές παραμέτρους Ο ΝΙV δεν φαίνεται να επηρεάζει τη θνητότητα

Πνευμονικό οίδημα και NIV Αποτελεσματικότερος στους ασθενείς με υπερκαπνία- Ο NIPPV δεν φαίνεται να υπερτερεί της CPAP Δεν φαίνεται να σχετίζεται με επιπλοκές όπως το OEM H προνοσοκομειακή χρήση του συνδυάζεται με θετικά αποτελέσματα.